ED Coding and Reimbursement Alert

Hint: For some debridements, you’ll need to measure the wound.

When patients present to the ED in need of skin debridement, your coding options can vary wildly. That’s because CPT® includes an array of options for this service, some of which are specific to the wound type. Check out the following three debridement questions and find out how to code these scenarios.

Get to the Bottom of Cycling Accident Debridement

Scenario 1: A patient presents to the ED following a cycling accident, which resulted in deep cuts on his left leg. The ED physician documents that the wounds measure 30 sq. cm and that they had gravel in them that needed to be removed. You report 11042 with +11045 and 10120 together. Is this the right coding selection? And if so, do you need a modifier?

Answer 1: Your classification of the wound as “deep,” and your provider’s documentation of the total area of the wounds, suggests that you should be able to go ahead and report 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) with +11045 (...  each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)) for the service rather than, say, 97597 (Debridement ... first 20 sq cm or less) and +97598 (... each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)).

When you do, though, you should make sure that your provider’s notes indicate that the procedure involved going deeper than the patient’s epidermis or dermis and into the subcutaneous tissue. Although CPT^® instructs to report the depth using the deepest level of tissue removed for a single wound, for multiple wounds, you should also make sure that the wounds were all debrided at the same depth, as CPT^® guidelines require you to “sum the surface area of those wounds that were at the same depth.”

Reporting 11042 and +11045 with 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) is trickier. The two services are distinct and not bundled per Correct Coding Initiative (CCI) edits, but debridement often involves the removal of foreign bodies as well as dead or damaged tissue from a wound. So, when you report 11042, you are essentially saying that your physician also performed the service described by 10120.

However, if your physician’s notes indicate that the debridement occurred in one anatomical area, say the knee, and the removal in another, say the shin, then you would have a case for documenting 11042 and +11045 with 10120. To be safe, you could append modifier 59 (Distinct procedural service) to either 11042 or 10120. This would not only alert your payer that the two services were separate but might also facilitate swifter processing of the claim.

Burns Require Separate Codes

Scenario 2: Your ED sees a rash of patients who present for sunburn due to particularly hot weather. In some cases, the emergency physician examines the area, notes redness with some blister formation, and diagnoses a mild burn requiring no further treatment. In other cases, the physician notes that he debrided the burn, even though he marks it as a “mild second-degree burn.” Should you use debridement codes, ED E/M codes, or neither?

Answer 2: The answer will depend on the documentation, but in the case when the physician examined the burn but did not provide any local treatment above and beyond the evaluation and management service, you’d report only the E/M code, such as 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity …) for the encounter.

If the physician provides local treatment of a first-degree burn, such as cleansing and ointment, then you’d report CPT^® 16000 (Initial treatment, first degree burn, when no more than local treatment is required). A first-degree burn affects the epidermis only. Usually these types of burns just involve erythema, but may also exhibit some swelling and/or minor pain. The most likely treatments in 16000  scenarios are cool towels, soothing balms, and topical medication application (substances such as Silvadene or triple antibiotic ointment). Dressings are possible but unlikely for most first-degree burns; they rarely require any treatment except application of moisturizer to soothe the skin. In some cases, the physician might apply a topical anesthetic.

For more serious burns with partial-thickness burns or second-degree burns, you would code with 16020-16030 (Dressings and/or debridement of partial-thickness burns, initial or subsequent ...) instead of a straight debridement code, since these codes include both the burn treatment and the accompanying debridement.

Tip: Depending on the extent of a partial-thickness burn, the ED physician may have to debride the burn or for those partial-thickness burns covering a larger body area, a specialist may have to be called to determine if surgical treatment is needed to prevent scarring.

When the physician performs partial-thickness burn treatment, he might use Silvadene following the procedure, but would most likely use some type of non-adherent dressing and additional antibiotic ointment depending on the location and the patient’s skin pigmentation. If you see documentation that contains some of the above elements, consider codes 16020-16030. Keep in mind these codes are applied for dressings and/or debridement of partial-thickness burns and are delineated based on the percentage of total body surface area affected.

Keep in mind: CPT^® ranks the codes by size based on the percentage of total body surface area involved in the burn. These include:

• 16020 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)),
• 16025 (… medium (eg, whole face or whole extremity, or 5% to 10% total body surface area)) and
• 16030 (… large (eg, more than 1 extremity, or greater than 10% total body surface area))

Does Debridement Fit into This Scenario?

Scenario 3: A patient presents to the emergency department after cutting the tip of his finger off while removing the grass catching attachment from his lawnmower. In addition to the E/M documentation, the chart notes read, “13:51 Hemostasis: Moderate amount of left phalanx of 3rd and 4th digits. Controlled using cauterization of both digital arteries of 4th digit, gel foam. Bleeding stopped.” Can you report debridement for this service?

Answer: In some cases, you can, but it will depend on the documentation.

Typically, this kind of ED presentation of a partially amputated finger includes stabilizing the injury, extensive undermining, and debridement before suturing the remaining skin over the exposed bone. This scenario would commonly be reported using a complex laceration repair code such as 13131 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm).

In cases where the exposed bone is too long for such a repair, a rongeur is often used to snip the bone back far enough to leave a suitable skin flap before the repair is performed. Depending on the documentation, you might consider reporting that extra work with code 11044 (Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less). Be advised that there are CCI edits between 11044 and the laceration repair codes.

So, depending on the nature of the bone debridement, only the complex repair code should be reported along with an appropriate E/M code, probably a level four or five service depending on the chart documentation. There is also a code for partial finger amputation, 26951 (Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure), but depending on the documentation that is less likely the service being provided in the ED.

Of note:

• 13131 has a 10-day global period and a total RVUs of 7.17 paying $258.40 in the facility.
• 11044 has a zero-day global period with total RVUs of 6.58, paying $237.14 in the facility.
• 26951 has a 90-day global period (including five follow up visits) with a total RVU of 18.42 and paying $663.84 in the facility; however, you would likely apply a 54 modifier (Surgical care only) unless you planned to provide the full global follow-up package.